Testicular Torsion

Understanding Testicular Torsion

Testicular torsion is a urological emergency that occurs when the spermatic cord, which provides blood flow to the testicle, twists and cuts off the blood supply. This twisting can happen spontaneously and causes immediate, severe pain and swelling. Without prompt treatment, the lack of blood flow leads to ischemia and death of testicular tissue, resulting in permanent loss of the affected testicle. The condition most commonly affects adolescent males between ages 12 and 18, though it can occur at any age, including in newborns and adults. The anatomical predisposition called the "bell clapper deformity," where the testicle is inadequately attached within the scrotum, allows it to rotate freely and increases the risk of torsion.

The urgency of testicular torsion cannot be overstated. Studies show that if blood flow is restored within 6 hours, there's a 90-100% chance of saving the testicle. This salvage rate drops to 50% at 12 hours and only 10% at 24 hours. Beyond 24 hours, testicular loss is almost certain. This time-sensitive nature makes it crucial for patients, parents, and healthcare providers to recognize the symptoms immediately and seek emergency care without delay. The condition requires surgical intervention to untwist the cord and secure the testicle to prevent future episodes.

Signs and Symptoms

Recognizing the symptoms of testicular torsion quickly can mean the difference between saving and losing a testicle. The presentation is usually dramatic and unmistakable.

Classic Presentation

• Sudden onset: Pain typically begins abruptly, often waking patients from sleep
• Severe pain: Intense, constant pain in one testicle
• Rapid swelling: The affected side becomes swollen within hours
• High-riding testicle: The twisted testicle sits higher than the normal one
• Abnormal position: The testicle may lie horizontally instead of vertically
• Absent cremasteric reflex: The testicle doesn't rise when inner thigh is stroked

Associated Symptoms

• Nausea and vomiting: Common due to severe pain
• Referred pain: Pain may radiate to lower abdomen or groin
• Scrotal redness: The scrotum may appear red and warm
• Difficulty walking: Pain makes normal movement difficult
• Fever: Low-grade fever may develop
• Urinary symptoms: Usually absent, helping distinguish from infection

Symptoms in Different Age Groups

Newborns

• Firm, enlarged scrotum
• Discoloration (red or blue)
• Inconsolable crying
• May be discovered during routine examination

Young Children

• Complain of "tummy ache" rather than scrotal pain
• Reluctance to walk or unusual gait
• Irritability and crying
• May not localize pain well

Adolescents and Adults

• Can clearly describe sudden testicular pain
• May report previous episodes of pain that resolved
• Often embarrassed to seek help immediately

Causes and Risk Factors

Understanding what causes testicular torsion and who is at risk helps with prevention and early recognition of this emergency condition.

Anatomical Causes

• Bell clapper deformity: Most common predisposing factor (12% of males)
• Inadequate fixation: Tunica vaginalis attaches too high on spermatic cord
• Long spermatic cord: Allows more rotation
• Horizontal lie: Testicles oriented horizontally rather than vertically
• Bilateral risk: Deformity usually affects both testicles

Triggering Factors

• Physical activity: Sports, exercise, or trauma
• Sleep: Many cases occur during sleep or upon waking
• Cold temperature: Cremasteric muscle contraction
• Rapid growth: During puberty
• Previous episodes: Intermittent torsion increases risk
• Spontaneous: Often no identifiable trigger

Risk Factors

• Age: Peak incidence 12-18 years, second peak in neonates
• Family history: Increased risk if father or brother affected
• Previous torsion: Higher risk in contralateral testicle
• Undescended testicle: Higher torsion risk
• Testicular tumors: Rare but can predispose to torsion

Types of Testicular Torsion

Testicular torsion can be classified based on the location of twisting and the age of occurrence.

Intravaginal Torsion

• Most common type: Occurs within the tunica vaginalis
• Age group: Primarily adolescents and young adults
• Mechanism: Bell clapper deformity allows rotation
• Degree: Can rotate 180° to 720° or more
• Both testes at risk: Deformity usually bilateral

Extravaginal Torsion

• Neonatal type: Occurs in newborns
• Location: Entire testicle and tunica twist together
• Timing: Can occur prenatally or postnatally
• Presentation: Hard, discolored scrotal mass
• Salvage rate: Very low due to prenatal occurrence

Intermittent Torsion

• Recurrent episodes: Testicle twists and untwists spontaneously
• Warning sign: Indicates high risk for complete torsion
• Symptoms: Episodes of severe pain that resolve
• Management: Elective orchiopexy recommended

Diagnosis

Rapid and accurate diagnosis is crucial for testicular salvage. Clinical evaluation remains the most important diagnostic tool.

Clinical Evaluation

• History: Sudden onset, severity, previous episodes
• Physical exam: High-riding testicle, horizontal lie, absent cremasteric reflex
• Cremasteric reflex: Absence strongly suggests torsion
• Prehn's sign: No pain relief with scrotal elevation (unlike epididymitis)
• Time since onset: Critical for prognosis

Imaging Studies

Color Doppler Ultrasound

• First-line imaging: If immediately available
• Finding: Absent or decreased blood flow to affected testicle
• Sensitivity: 88-100% in experienced hands
• Limitation: Should not delay surgery if high suspicion
• Additional findings: Enlarged testicle, hydrocele

Nuclear Scintigraphy

• Alternative imaging: If ultrasound unavailable
• Cold spot: Indicates absent perfusion
• Limitation: Time-consuming, less available

Laboratory Tests

• Urinalysis: Usually normal (helps rule out infection)
• CBC: May show mild leukocytosis
• Not diagnostic: Labs should not delay treatment

Clinical Decision Making

• High suspicion = surgery: Don't wait for imaging
• Negative exploration better than missed torsion: 15-30% negative exploration rate acceptable
• "Time is testicle": Every hour of delay decreases salvage rate

Treatment

Treatment of testicular torsion is surgical emergency. The goals are to restore blood flow quickly and prevent future torsion.

Manual Detorsion

• Temporary measure: May buy time before surgery
• Technique: "Open the book" - rotate outward
• Direction: Left testicle counterclockwise, right clockwise
• Success signs: Pain relief, normal position
• Still need surgery: Even if successful
• Limitation: May worsen torsion if wrong direction

Surgical Treatment

Surgical Exploration

• Urgent procedure: Should occur within 6 hours
• Scrotal approach: Midline raphe incision
• Detorsion: Untwist spermatic cord
• Viability assessment: Color, bleeding, response to warm saline
• Intraoperative Doppler: May help assess flow

Orchiopexy (Testicle Fixation)

• Viable testicle: Suture to scrotal wall at 3 points
• Non-absorbable sutures: Prevent future torsion
• Bilateral procedure: Always fix both testicles
• Dartos pouch: Alternative fixation technique

Orchiectomy (Testicle Removal)

• Non-viable testicle: Black, no bleeding after detorsion
• Infection prevention: Dead tissue can cause abscess
• Prosthesis option: Can be placed immediately or later
• Psychological support: Important for patient

Postoperative Care

• Pain management: Adequate analgesia essential
• Scrotal support: Reduces swelling and discomfort
• Ice packs: First 24-48 hours
• Activity restriction: No sports for 4-6 weeks
• Follow-up: Monitor for atrophy or complications
• Fertility counseling: If orchiectomy performed

Prognosis and Complications

The outcome of testicular torsion depends primarily on the time from onset to treatment and the degree of torsion.

Salvage Rates by Time

• 0-6 hours: 90-100% salvage rate
• 6-12 hours: 50-70% salvage rate
• 12-24 hours: 20% salvage rate
• >24 hours: <10% salvage rate
• Degree matters: Greater rotation = faster ischemia

Complications

Immediate Complications

• Testicular loss: Due to delayed treatment
• Infection: Rare with proper technique
• Hematoma: Usually resolves spontaneously
• Wound issues: Dehiscence, infection

Long-term Complications

• Testicular atrophy: Even after successful detorsion
• Decreased fertility: Possible with unilateral loss
• Hormonal effects: Usually compensated by remaining testicle
• Psychological impact: Body image, masculinity concerns
• Chronic pain: Rare but possible

Fertility Considerations

• Unilateral orchiectomy: Usually maintains fertility
• Bilateral torsion: Rare but devastating for fertility
• Sperm banking: Consider before surgery in adults
• Anti-sperm antibodies: May develop after torsion
• Semen analysis: Recommended after recovery

Prevention

While testicular torsion cannot always be prevented, certain measures can reduce risk and prevent recurrence.

Preventive Orchiopexy

• Contralateral fixation: Always done during torsion surgery
• Intermittent torsion: Elective bilateral orchiopexy
• Family history: Consider prophylactic fixation
• Bell clapper deformity: If discovered incidentally
• Patient education: Importance of immediate care

Risk Reduction

• Protective equipment: During contact sports
• Awareness: Educate about symptoms
• Prompt treatment: Don't wait to see if pain improves
• Follow-up: After episodes of testicular pain

Education Points

• Parents: Know symptoms and urgency
• Adolescents: Overcome embarrassment to seek help
• Schools: Health education about testicular problems
• Emergency departments: Triage as high priority

Differential Diagnosis

Several conditions can mimic testicular torsion. Distinguishing between them is crucial but should not delay treatment if torsion is suspected.

Torsion of Testicular Appendix

• Common mimic: Especially in prepubertal boys
• Blue dot sign: Visible through scrotal skin
• Less severe pain: More gradual onset
• Normal blood flow: On ultrasound
• Conservative treatment: Usually resolves with NSAIDs

Epididymitis/Orchitis

• Gradual onset: Pain develops over days
• Urinary symptoms: Dysuria, frequency common
• Positive Prehn sign: Relief with elevation
• Risk factors: STDs, UTIs, instrumentation
• Increased blood flow: On Doppler ultrasound

Trauma

• Clear history: Direct blow or injury
• Hematocele: Blood in tunica vaginalis
• Testicular rupture: Requires surgical repair
• Can trigger torsion: Trauma may precipitate

Other Conditions

• Incarcerated hernia: Palpable mass, bowel symptoms
• Testicular tumor: Painless mass usually
• Idiopathic scrotal edema: Painless swelling
• Henoch-Schönlein purpura: Scrotal involvement possible
• Referred pain: Kidney stones, appendicitis

Living After Testicular Torsion

Recovery from testicular torsion involves both physical and psychological aspects. Understanding what to expect helps with adjustment.

Physical Recovery

• Surgical recovery: 1-2 weeks for incision healing
• Return to activities: 4-6 weeks for sports
• Scrotal changes: Swelling resolves over weeks
• Testicular size: May notice atrophy over months
• Sexual function: Usually unaffected

Psychological Adjustment

• Body image: Concerns about appearance
• Masculinity: May question with testicle loss
• Anxiety: Fear of recurrence in other testicle
• Support groups: Helpful for adjustment
• Counseling: May benefit some patients

Long-term Monitoring

• Regular self-exams: Check remaining testicle
• Annual check-ups: Monitor hormone levels if needed
• Fertility testing: If planning family
• Prosthesis consideration: If desired for symmetry
• Ongoing education: Know warning signs

Special Populations

Certain groups have unique considerations regarding testicular torsion diagnosis and management.

Neonates

• Bilateral risk: Check both testicles
• Salvage rate low: Often torsion occurred in utero
• Controversial management: Some advocate observation
• Contralateral orchiopexy: Recommended by many

Undescended Testicle

• Higher torsion risk: Especially with abdominal testicle
• Difficult diagnosis: Can't examine directly
• Abdominal pain: May be only symptom
• Urgent exploration: If suspected

Intellectually Disabled Patients

• Communication barriers: May not report pain clearly
• Behavioral changes: May be only sign
• Lower threshold: For surgical exploration
• Caregiver education: Critical for early detection